by Fyezah Jehan; MBBS, MSc., Assistant Professor of Paediatrics and Paediatric Infectious Disease, Aga Khan University
In a low-income neighborhood of Karachi, Pakistan, a community health worker (CHW) has just finished counting the respiratory rate of Naeema, a 6-month-old child who has come in with her second episode of fast breathing pneumonia in a year. She had received a three-day course of amoxicillin with resolution of symptoms only three months back. “Why is she having these symptoms again?” quizzes Naeema’s mother of the CHW who now appears concerned about the recurrence.
This is not an infrequent occurrence in our peri-urban setting of Bin Qasim Town, where about 11% of children between 2 to 59 months of age may present with a recurrent episode of fast breathing pneumonia in a year.
While recurrent community acquired pneumonia, characterized by 2 or more episodes of pneumonia occurring within a year, or three episodes ever with inter-critical radiographic clearance of lung opacity, is a well described clinical entity with established risk factors, less is known about World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) recurrent fast breathing pneumonia.
In our recently concluded randomized controlled trial of fast breathing pneumonia (RETAPP), a well characterized population of 4002 children aged 2-59 months in a low middle income neighborhood of Karachi, Pakistan were followed over variable periods of time. For enrolled children whose period of follow-up was at least 12 months, up to 11% (454) had episodes of recurrent fast breathing. At least 50% (227) of relapsers had more than a single relapse - 3 or more episodes of fast breathing pneumonia during their period of follow-up.
Possible risk factors include use of solid fuel and lack of pneumococcal immunization. Other possible factors may be atopy/asthma, overcrowding, and prematurity; however, these require more study and exploration as these children represent a subset who will receive repeated courses of antibiotics, which has implications for their growth and development of antimicrobial resistance.
For now, Naeema will receive another course of oral antibiotics as per WHO IMCI. “What is the chance of this happening again?” asks Naeema’s mother. Nonplussed, the CHW replies, “Only time will tell.”